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The organisation of veterinary specialisation was described as ‘confusing and opaque’ by Philip Lowe in his 2009 report into veterinary expertise in food animal production. Here, Andrew Gardiner, Professor Lowe and Justin Armstrong contrast the situation in the medical field with that in veterinary medicine and argue that a coherent model of veterinary specialisation is vital to sustaining the profession's status and public good functions
WHO counts as a veterinary specialist? To a large extent, the answer depends on who is asking. To the client inquiring in general practice, it could be Mr A ‘who does most of our horse work’ or Ms B ‘who has a special interest in eyes’. To the vets in the same practice, it could be colleague C ‘who does all the bovine fertility work’ or colleague D ‘who has an RCVS certificate in dermatology’.
An experienced colleague in a neighbouring practice who has an RCVS certificate and an excellent local reputation and who spends most of his time taking orthopaedic referrals could also be considered a specialist. It could also be a vet with an RCVS or European diploma working in a single or multidisciplinary private referral centre; and it could be an academic clinician, with a diploma and a PhD, working in a veterinary school department.
From this diverse range of people, it is only the last two who are likely to be eligible for consideration as RCVS- or European-recognised specialists. The meaning and implications of this designation are, however, far from clear. The lack of functional differentiation of specialist veterinary roles is problematic, both for the profession itself and its public. As the Lowe report commented: ‘Recognised specialisms should provide a means to develop and provide complex and advanced treatments and services in line with customers’ priorities and needs. In principle, therefore, specialisation should play an important role in signalling to the customer that particular and authoritative skills or expertise are available. However, not only is the organisation of veterinary specialisation confusing and opaque, but the profession's concept of specialisation is inward-looking and orientated towards fellow professionals rather than aimed at informing the customer. The customer is not even given the reassurance that someone who claims a specialism is professionally sanctioned to do so.'
Two broad types of specialisation are currently at work in the profession: by species, seen most clearly within the BVA's specialist divisions; and by clinical techniques/disciplines, seen most clearly in the structure and organisation of the veterinary referral hospital. These concepts of specialisation are of a different character: one emphasising the informal, cooperative, experiential specialisation of practice; the other replicating the formal consultant model of human hospital medicine, with its clear delineation of boundaries of individual expertise.
Tacit acceptance of the medical model of specialisation has occurred in the small animal sector, and with the growth of this sector, this could become the dominant model. It is based on formal referral to discipline-based consultants. In British hospital medicine, the rise of the consultant entailed a progressive withdrawal of ‘ownership’ of the diagnosis and treatment of particular areas of the body from general practitioners. For example, before cardiology was ‘disciplined’, general practitioners would treat heart conditions. After ‘disciplining’, GPs were forced to refer, and to defer, to the new medical elite of cardiology consultants who specified what could be treated and how. Similar processes of disciplinary and professional closure occurred in relation to other areas of the human body. Medical general practice is now primarily a biographical type of medicine; it may not be too much of an exaggeration to say that the main clinical technique GPs use is speech (talking and listening).
Veterinary general practice is quite different, and this has important consequences as to how specialisation is organised and how specialists might interact with their colleagues. An important issue is how much specialisation a small, mainly private sector profession can sustain and how labile such services may be in terms of practice economics and how much people and government are prepared to pay for animal health. There is therefore some danger in uncritically accepting the human medical model of specialisation as setting the future direction of veterinary specialism.
The ways in which human and veterinary medicine are organised and delivered are, in reality, quite different. Human medicine relies on the vast supporting infrastructure of the NHS, which is integrated into clinical training and postgraduate specialisation. It is also heavily prescriptive; for example, of what doctors may do at each stage of training, which drugs they may use, and so on. In this vast, complex and carefully regulated system, integrated care is a function of the whole. Moreover, the medical profession wields considerable influence and the NHS is a politically sacred cow.
In contrast, vets have always been able to exercise great flexibility in what they do, in what context, and with what species. This breadth of outlook has been an important defining feature of the profession's self-identity. It distinguishes veterinary medicine from human, where the core training is a platform from which to develop specialisation and general medical practice acts as the gateway to other branches of clinical medicine. In veterinary medicine, CPD requirements notwithstanding, basic training has conventionally been seen as sufficient in itself to equip veterinarians for a lifetime's practice. Moreover, for the large majority of cases, veterinary general practice acts as a clinical one-stop shop for animals and their keepers, with integrated care being a function of the individual vet or practice. Thus, in contrast to the medical GP, ordinary veterinarians perform a great variety of tasks, many of them actually rather specialised in themselves.
‘The role of veterinary GP is clearly not akin to that of the GP in human medicine, nor is the role straightforwardly the opposite or counterpart of the specialist’
Indeed, vets in general practice pride themselves on their ability to turn their hand to many things. At different times of the day they may be called upon to act as diagnostician, physician, anaesthetist, obstetrician, surgeon or nurse, and to do so in respect of various species. They are also running a small business and employing a range of staff, professional and lay. The term ‘GP’ does not capture this identity of the vet as a ‘jack of all trades’ or ‘polyspecialist’.
The role of veterinary GP is clearly not akin to that of the GP in human medicine, nor is the role straightforwardly the opposite or counterpart of the specialist. In human medicine, the remits of the specialist and the GP are very clearly differentiated and enforced. In veterinary medicine, this is far from the case. A vet GP might perform many of the functions that a formal veterinary specialist might want to claim as his or her own. Indeed, much clinical CPD, largely provided by specialists, consists of educating GPs to perform more challenging and complex tasks: fixing difficult fractures, performing more elaborate diagnostics, and so on. In terms of demarcating specialist boundaries, this seems counterproductive. However, it is in keeping with the informal, experiential model of specialisation. Indeed, the RCVS certificates have traditionally been regarded by many as quasispecialist qualifications for vets in practice. They do underpin much of the referral work that is done in private practice.
Compared to medicine, the veterinary profession is thus marked by much looser boundaries over ‘who owns what’ in terms of clinical techniques and procedures. It is the absence of a clear differentiation of roles that lies behind the resistance in the profession to the formal differentiation of its expertise. Fully engaging with this reality is one of the main challenges in reshaping veterinary specialisation. To capture the unique qualities and strengths of veterinary medicine's cadre of ‘polyspecialist’ GPs requires a nuanced view of specialist-generalist interaction that plays to the profession's strengths.
Historically, the veterinary profession has strongly resisted formal differentiation of its expertise. Such drawing of boundaries, and the exclusion it inevitably entails, was seen by many as a threat to the unity of the profession, to its historic self-identity and to the flexibility of veterinary careers and the veterinary labour market. This feeling is represented in debates on undergraduate ‘tracking’, which essentially begins the specialising process before graduation in order to cope with information overload in undergraduate training, but which, some believe, risks compromising the flexibility and adaptability that are vital features of a small profession.
There is no denying that pressures to specialise veterinary expertise at all levels are real and persuasive. They come from scientific advances, technological developments and market demands. What is contentious is not the need to develop and refine specialist skills, but agreement on the nature of the contribution of formal specialists and their place in the veterinary profession as a whole. It is too simple to cast extension of specialist skills as a good or bad thing. Different sectors within the profession also have different notions of what specialisation entails. The work of a dairy, poultry or pig specialist is not restricted (or even mainly focused) on consideration of the individual animal body; the ‘animal body’ here is much more likely to be the whole herd or flock. The specialist role will incorporate a wide variety of management, preventive and agricultural economics issues, as well as attention to pressing public good issues such as animal welfare. Efforts to institutionalise a particular notion of a veterinary specialist should therefore relate to the broader processes of specialisation operating across the profession, and should avoid automatically accepting the medical model. If the profession's status and public good function are to be sustained, they must be underpinned by a strong sense of purpose that goes beyond narrow ideas of serving market demands. A coherent model of specialisation will be a key contribution to this end.
This article is the third in a series of discussion articles produced for Veterinary Record by a group of social scientists and historians drawn together by Philip Lowe, author of the 2009 report ‘Unlocking potential: a report on veterinary expertise in food animal production’. The articles reflect on some of the challenges for the profession posed in his report and aim to stimulate debate about the wider role of vets in relation to government and society. Previous articles in the series are listed on p 356
This article draws on research funded as part of the UK Research Councils' Rural Economy and Land Use Programme (RELU) (Award RES-229-25-0025). RELU is a collaboration between the Economic and Social Research Council, the Natural Environment Research Council and the Biotechnology and Biological Sciences Research Council, with additional funding from Defra and the Scottish Government.
Andrew Gardiner is a clinical lecturer in small animal practice at the Royal (Dick) School of Veterinary Studies. He has research interests in veterinary history, sociology and human-animal relations.
Philip Lowe is the Duke of Northumberland Professor of Rural Economy at the Centre for Rural Economy at Newcastle University, and Director of the UK Research Councils' Rural Economy and Land Use Programme.
Justin Armstrong is a postgraduate researcher at the Centre for Rural Economy at Newcastle University, studying veterinary expertise and the rural economy.
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